When people buy insurance, they buy it as protection against any unforeseen health problems or accidents—hence the title “insurance.” Most people go over the details of what an insurance plan includes and what it can do for them. No one wants to purchase an insurance plan from a company that does not follow through with what it promises to do. Most people buy insurance to provide peace of mind, and to provide a safety net should anything occur.  However, it is an unfortunate reality that sometimes insurance companies leave their customers out on their own. Sometimes companies will fail to provide the proper coverage or assistance when it is needed all because of loopholes or errors. This is wrong. In the end, it is the customer that suffers the most.

Recently, the Anthem EPO lawsuit has brought to light insurance denial issues for its EPO members. At Stop Health Insurance Denials, we are a team of highly professional insurance lawyers who have helped many individuals across the nation with resolving problems with their insurance. We have handled many types of situations involving insurance denial, and we know how it can significantly affect anyone. Our team is looking to help any individuals affected under the Anthem EPO lawsuit. With our expertise and our experience, you can be sure that you will receive the best assistance around. We believe that you have been unfairly treated and you deserve the proper compensation for your losses.

EPO vs. PPO

Many of the issues surrounding Anthem involves EPO and PPO memberships. Yet, it may be unclear of what exactly is the difference between the two. These two acronyms are different types of health insurance plans. PPO, or “preferred provider organization,” is usually a more expensive option, but it provides more benefits. This mainly includes a larger network of health care providers that will be covered under the insurance, and an option to still be covered even when going out of the network. EPO, or “exclusive provider organization,” on the other hand, is a less expensive option. Under this plan, members are on a more limited network of health care providers, and they do not have the ability to go outside of the network to receive covered health care.

Each plan presents different benefits and at different prices. Because of this, most customers carefully go through the details of their plans so that they can be sure that the health care providers they visit are covered and that they will not have to pay for the services out of their own pockets. Unfortunately, there are situations in which an insurance company may switch or change your plan without your knowledge. Under federal laws, this is illegal. The lawsuits described below provides a good example of what may happen should this happen to you.

What Is the EPO Lawsuit About?

In 2014, multiple lawsuits were filed against Anthem Blue Cross. These lawsuits involved multiple issues regarding the network sizes, benefits, and EPO members. All presented issues of insurance denials and unlawful behavior on the part of Anthem.

One class-action lawsuit argued that Anthem misled their customers about the benefits they would receive under their plans. It involved EPO (“exclusive provider organization”) members who believed that under this plan they would be able to have the same health care providers in their network from before. Many of the customers who had switched from PPO (“preferred provider organization”) plans to EPO plans switched on the assumption of staying within the same network while paying a reduced price. Within the lawsuit, it is alleged that Anthem falsely advertised its product when customers were made to switch plans that were compliant with the Affordable Care Act. They believed that they were just switching to a plan similar to the PPO they were already on. However, this was not the case. It turns out they were placed on an EPO plan which has a more limited network of health care providers and did not provide the option to be covered out of the network.

The lawsuit claimed that Anthem fraudulently marketed the details of the plan. They did not explain how, under the new plans, their networks would become more limited than before. Also, due to this mistake, customers who went to health care providers not covered under the plan were forced to pay out-of-pocket. More than this, the company was delayed in sending out customers’ insurance cards, forcing these customers to pay out-of-pocket for doctors and health care providers within the network.

Another issue that Anthem members faced during this period was receiving inaccurate membership ID cards. For customers who were unknowingly switched from a PPO plan to an EPO plan, some received insurance cards that stated “PPO.” This led customers to believe they still had a PPO plan; thus, they would go to their previous doctors or ones covered under the PPO. However, when they would visit these health care providers, they would find out they were not actually covered as they were actually EPO members. Because of this inaccuracy, these members would have to pay out of their own pocket for these visits and medical bills.

Even though these were Anthem’s mistake, they still refused to cover these customers’ claims. Despite confusing their customers and presenting false information, they still made their customers pay of their own pockets for services that they believed to be covered under their plans. Unfortunately, this led to suffering for many customers. Not only would they suffer financially from these errors, but would also suffer in the physical sense since they might not have received the proper health care services that they would have needed.

Malpractices

The Anthem EPO lawsuit brings up a couple of malpractices that commonly occur within the insurance industry. These usually are schemes in which insurance companies treat their customers unfairly while simultaneously profiting. The lawsuit brings up a couple of violations. These violations include a breach of good faith and fair duty, breach of contract, and misrepresentation of information which are all contained under California’s Business and Professional Code § 17200. Also, these lawsuits also presented the claim that Anthem violated federal laws such as the Code of Federal Regulations § 147.106, or the guaranteed renewability of coverage law.

These are just some of the ways in which an insurance company may violate a policyholder’s rights, and lead to a denial of coverage. Any type of behavior that unfairly treats the policyholder may be taken up in court.

Bad Faith

As brought up by the lawsuit, it is argued that Anthem was in breach of its duty of good faith and fair dealing. In other terms, it can be stated that they operated in bad faith. Unfortunately, bad faith dealings and practices are common tactics within the insurance industry that can hurt policyholders in many different ways. Usually, practices of bad faith by insurance companies are means through which they may seek to escape from their lawful obligations to investigate a claim for you as a policyholder. A list of common bad faith practices includes, but are not limited to:

  • Unjustified denial of coverage
  • Failing to inform a policyholder of important information
  • Failing to investigate a policyholder’s claim
  • Refusing to pay an insurance claim without investigating
  • Failing to pay or deny a claim within a well-reasoned amount of time
  • Failing to confirm or deny coverage within a well-reasoned amount of time
  • Failing to provide a reasonable explanation for denial of a claim
  • Failing to enter negotiations regarding a settlement for a claim
  • Failing to respond to a time-sensitive matter
  • Failing to disclose a policy’s limits

All of these and more represent types of situations that may constitute bad faith. Of course, every individual’s situation is different and the circumstances and details may lead to different outcomes. Usually, bad faith may be understood as a breach of trust between the customer and the insurance company. This occurs when a company fails to live up to its promises, and when it leaves its customers to deal with issues on their own. This goes against the role of an insurance company since they are meant to provide a safety net should anything happen. The Anthem EPO lawsuit describes some behavior by Anthem that may be considered under these situations.

First of all, Anthem presented false and inaccurate information to its customers. They were led to believe that they had a certain coverage for health care services. Also, they failed to deal with their customers’ claims and even denied them, despite the issues being the fault of the company. The lawsuits were filed as a way to receive reimbursement for the losses incurred, but also for the damages that their errors may have caused.

Breach of Contract

Any and all insurance policies are considered to be a contract between the insurance company and the policyholder. Both the individual policyholder and the insurance company have certain responsibilities and rights when it comes to policies. Any violation of anyone rights, terms of an agreement, and insurance guidelines will be considered a breach of contract.

Misrepresentation of Information

When Anthem states that the switch from PPO membership to EPO membership is a renewal it is a misrepresentation of information to the customer. Under state and federal laws, this cannot be a renewal since the switch causes a significant change in coverage. The packet that was sent out to the PPO members was misleading since it never really indicated that the coverage plan that they were going to be “renewed” under was more limited in scope and did not provide the same level of coverage. The packet only let them know that the plan they were getting for the next year would be similar to the one they were on—which was false. Under CFR § 147.106, Anthem should have provided their customers with a proper notice about the discontinuation of their original plan, and they should have allowed them the option to enroll in a new plan.

Also, the inaccurate membership cards are another misrepresentation. Since the cards were labeled as PPO, rather than EPO, these members were led to believe they had a certain level of coverage. However, this was not so, and it costs the customers much more than they wanted.

An Insurance Policyholder’s Rights

Depending on what state you may reside in, there are laws regarding an insurance policyholder’s rights. It is vital to understand that your rights as a policyholder can vary from state to state. However, these laws, in general, are meant to protect the policyholder and to ensure that the insurance they purchase is made in good faith by the insurance company.  Also, by knowing about your rights as a policyholder, you may be proactive about making decisions and fighting bad insurance practices.

Even though these may not represent all of the points in every state, below are just some rights that may be guaranteed under state law. Of course, it is a good idea to research your state’s laws regarding health insurance and your rights as a policyholder. Possible rights may provide the following:

  • Your insurance must investigate, process, and pay your claim in good faith, quickly, and in full
  • Your insurance company must treat you fairly
  • Your insurance company must honestly communicate all details regarding your policy and any rights related to the claim
  • Your insurance company can, in no way, misrepresent information
  • Your insurance company cannot discriminate against its policyholders
  • Your insurance company must respond to you within a certain amount of time
  • Your insurance company must let you know about any, and all, deadlines

These are just some rights that may be guaranteed by your state. These provide a general idea of how insurance companies should treat their members. Depending on your states’ specific laws regarding insurance and policyholders, you may be able to take your case to court should they violate any of your rights like the ones listed above.

How Can A Lawyer Help You If You Are Affected?

If you have been affected by the actions described under the lawsuit, then you may be eligible to receive certain reimbursements or bad faith damages as part of the class action settlement agreed to by Anthem Blue Cross. This applies to policyholders affected by Anthem falsely advertising ACA-compliant health services and by failing to disclose the fact that new ACA plans were much more limited than previous ones. The settlement is meant to resolve the issues caused by their mistakes and illegal practices, and to prove financial relief for costs that may have been a result.

Of course, you may be unsure of what to do or how to receive any reimbursement. This is where a qualified insurance lawyer can help you. With their assistance, they can help in determining if you fit the requirements that are necessary in order to receive any settlement payment form the insurance company. The Anthem customers that would receive reimbursement must have been covered within a certain time frame to be considered.

Lastly, if you have been affected by insurance denial issues similar to those described in the lawsuit, then you may have a case. It is not uncommon for insurance companies to use improper practices when dealing with their customers. Even if you feel that your insurance company has violated your rights as a policyholder, you may still be able to file a suit. You may seek the assistance of an insurance lawyer to help you with this. No insurance company should leave their customers without the proper benefits that they should receive under the plans that they have purchased. As stated before, insurance is meant to provide peace of mind and act as a safety net.

Finding an Insurance Lawyer Near Me

For anyone that has had an issue with their insurance company, they may know how stressful the situation can be. Especially with health insurance, you mainly use it when you need it most, and, in this case, it is for you and your family’s health. So, cases of health insurance denials are especially significant since not only may you suffer financially, but you may suffer health-wise by not receiving the proper treatment. With the recent Anthem EPO lawsuit, we can see how insurance companies may neglect their responsibilities at the expense of their members.

Are you an Anthem EPO member who has suffered from the company’s errors regarding your coverage? If this the case, you may contact Stop Insurance Denials at 310-695-5241 today to receive help. Insurance should be there to help you when you need it the most. As an EPO member, you may be able to receive reimbursements for any out-of-pocket payments you have made as a cause of the company’s mistakes. No matter where you may be in the nation, our insurance lawyers are waiting to hear from you about your case. By contacting us, we can begin reviewing your case and start the process of recovering any losses you may have incurred. Our team will be at your side, helping you every step of the way.